The Strategic Implications of Iran's STD Epidemic

In the 5th Century BC, the "Persian disease" noted by Hippocrates probably was bubonic plague; in 8th-century Japan, it meant the measles. Today it well might mean chlamydia. Standout levels of infertility among Iranian couples, a major cause of the country's falling birth rate, coincide with epidemic levels of sexually transmitted disease. Both reflect deep-seated social pathologies. Iran has become a country radically different from the vision of its theocratic rulers, with prevailing social pathologies quite at odds with the self-image of radical Islam.

Iran's fertility decline from about seven children per female in 1979 to just 1.6 in 2012 remains a conundrum to demographers. Never before in recorded history has the birth rate of a big country fallen so fast and so far. Iran's population is aging faster than that of any other country in the world. In 2050, 30% of its people will be over 60, the same ratio as in the United States but with a tenth of America's per capita GDP. I see no way to avoid a social catastrophe unique in human experience. Since I first drew attention to Iran's demographic implosion a decade ago, I have heard not one suggestion as to how Iran might avert this disaster, despite some belated efforts to raise the birth rate.

Iran's fertility decline remains a conundrum to demographers. Never before has the birth rate of a big country fallen so fast and so far.

Iran was the first Muslim country to achieve mass literacy, thanks in large part to the Shah's Literacy Corps of the 1970s. Muslim total fertility rates correlate closely with female literacy rates: As soon as Muslim women have the means to make their own decisions, they reject traditional society and the fertility behavior associated with it.

But another factor is at work. Iran has the highest incidence of lifetime infertility of any country in the world, estimated at between 22% and 25% in separate Iranian government surveys. Roughly a quarter of Iranian couples, that is, are unable to bear children.

By comparison, lifetime infertility ranges from 11% in Europe and 15% in India. The Iranian data are more extensive than in most other countries because Iran's government has devoted enormous resources to finding explanations and remedies for its uniquely high infertility rate.

One explanation for Iran's strikingly infertility rate is the high level of consanguineous (cousin) marriages, that is, inbreeding. Azadeh Noaveni writes:

Iran, like other Middle Eastern countries, has an extremely high infertility rate. More than 20 percent of Iranian couples cannot conceive, according to a study conducted by one of the country's leading fertility clinics, compared with the global rate of between 8 and 12 percent. Experts believe this is due to the prevalence of consanguineous marriages, or those between cousins. Male infertility is "the hidden story of the Middle East," says Marcia Inhorn, a Yale University medical anthropologist and a specialist on assisted reproduction in the region.

This surmise probably is wrong. Iran's rate of cousin marriage is about 25%, lower than most of the Middle East. We do not have permanent infertility data for most Middle Eastern countries, but the fertility rate in neighboring Iraq (at four children per female) is more than double that of Iran. In fact, the proportion of cousin marriages is inversely correlated with fertility, because women in the sort of traditional society that fosters cousin marriage tend to bear more children.

A more probable cause of Iran's extremely high rate of infertility is sexually transmitted disease, particularly chlamydia, the most common bacterial STD and one likely to go undetected in countries with poor public health systems. This may seem incongruous, for the Islamic Republic of Iran represents itself as the guardian of social standards against Western decadence. Nonetheless, the government's own data strongly support this inference.

A 2013 paper by a team of Iranian researchers, "Effects of Chlamydia trachomatis Infection on Fertility: A Case Control Study," observes:

The molecular prevalence of C. trachomatis was 12.6% in woman in Tehran, the capital of Iran, and in another study it was 21.25% in women attending Shahid Beheshti Hospital in Isfahan, Iran. Considering the different prevalence rates of C. trachomatis infection in Iran, it is vitally essential to assess the impact of C. trachomatis on the reproductive health of women.

Iran appears to have the world's highest rate of lifetime infertility because it also has the world's highest rate of STD infections.

By contrast, the US Center for Disease Control reports a rate of 643 cases per 100,000 American women, or an infection rate of only 0.6%. Among sexually active females aged 14-19 years, the American population segment most at risk, the infection rate was 6.8%. Globally, the chlamydia infection rate was 4.3% in 2008, according to the World Health Organization.

Iran appears to have the world's highest rate of lifetime infertility because it also has the world's highest rate of STD infections. This is a tentative conclusion, to be sure, because Iran's fairly primitive public health system has produced only fragmentary evidence about STD infection rates. It is nonetheless convincing.

Iranian authorities have made dire warnings about epidemic rates of STD infection. As Muftah.org reported in late 2013:

On World AIDS Day (December 1st), Iran's Health Minister Hassan Hashemi, announced that Iran is facing a dramatic increase in HIV diagnoses. Speaking at an AIDS-awareness conference at the Ministry of Health, Hashemi noted that over the past eleven years, AIDS cases have increased nine-fold. He further warned that the lack of sexual education and persistent social taboos surrounding sexually transmitted diseases (STDs) in Iranian society were factors in this alarming trend.

Just weeks later on December 18th, news about increases in Iran's STD infection rates again made national headlines. Mostafa Aqlyma, the President of the Association of Social Workers told the Iranian Labor News Agency (ILNA) that the country was experiencing an outbreak of genital warts and that "nearly one million people have been affected" by the virus. Aqlyma described the epidemic as "more dangerous than HIV," and noted that he had treated almost ten times the number of male patients this year as compared to last.

That is at odds with the Islamic Republic's image in the West, but it is quite consistent with the complaints of Iranian officials about the widespread increase in casual sexual relationships. Premarital sex is illegal in Iran, but the peculiar Shi'ite institution of Sigha, or temporary marriage, allows Iranians to engage casual sex with official as well as clerical sanction. Iran's Sharzad news service reported in 2014:

Figures released by the Iranian National Statistics Office indicate that Sigha - temporary partnership - is on the rise, while fewer and fewer people are marrying in the conventional way. According to the deputy justice minister, Sigha rose by 28% in 2012 and by a further 10% in the first half of this year. Sociologist Mustafa Aghlima told the ISNA news agency: "The increase in Sigha at the cost of fewer proper marriages means the collapse of family life and its cultural values."

I have been unable to find statistics on the total number of Sigha liaisons in Iran, but anecdotal evidence suggests that they are very common. The Azerbaijani website Trend reports:

Some 84.5 percent of Iranians aged 18 to 29 years are in favor of temporary marriage, Iranian Shargh newspaper reported citing Iran's Youth Affairs and Sports Ministry's study. According to the study which has conducted tests among 3,000 young people of Iran's 14 cities, about 62.9 percent of Iranian youth avoid temporary marriage due to fear of bad reputation. During the last several years, number of websites which offer temporary marriage services to Iranians has increased.

Former President Mahmoud Ahmadinejad once said that Iranian women who decline to bear children are guilty of "genocide" against their nation.

The survey seems to conclude that the vast majority of young Iranians the support the idea of temporary marriage and can arrange one online, while 63% decline to do so - which suggests that 37% do.

Prostitution also is quite common in Iran, although I have been unable to find an official estimate later than a 1994 International Labor Organization estimate of 300,000 working prostitutes. Estimates vary widely, but the Iranian authorities acknowledge that it is a serious social problem.

Iran's leaders are well aware of the consequences of the sudden aging of its population; former President Mahmoud Ahmadinejad said that Iranian women who decline to bear children were guilty of "genocide" against their country:

'Two children' is a formula for the extinction of a nation, not the survival of a nation … The most recent data showing that there are only 18 children for every 10 Iranian couples should raise an alarm among the present generation … This is what is wrong with the West. Negative population growth will cause the extinction of our identity and culture. The fact that we have accepted this places us on the wrong path. To want to consume more rather than having children is an act of genocide.

Iran promotes In Vitrio Fertilization (IVF) as a solution to infertility, as Ms Moaveni reported at Foreign Policy:

Women chat openly about IVF on state television, couples recommend specialists and trade stories on Internet message boards, and practitioners have begun pushing insurance companies to cover treatment. And the state runs subsidized clinics, so the cost for treatment is lower than almost anywhere else in the world: A full course of IVF, including drugs, runs the equivalent of just $1,500.

IVF is a godsend for couples who wish to have children but cannot conceive otherwise, but it is unlikely to have much of an impact on Iran's overall numbers.

Iran's economy will be crushed under an avalanche of elderly dependents a generation from now.

Directly or indirectly, Iran's childlessness stems from a deep and intractable national anomie, a loss of personal sense of purpose in a country whose theocratic elite has no more support at the grass roots than did the Communist Party of the Soviet Union in the 1980s.

We know how this will end: Iran's economy will be crushed under an avalanche of elderly dependents a generation from now. What we do not know is what will happen en route to the end. The sad task of Iran's neighbors is to manage its inevitable decline and prevent its own sense of national tragedy from turning into tragedies for other peoples as well. Iran's position is without precedent among the nations of the world. It knows as a matter of arithmetic that it has no future. Its leadership feels that it has nothing to lose in strategic adventures, which means that the rest of the world should take no chances with Iran.